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y Office of Zoning Administr4torv o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d _ .9) <br /> THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and lci as H <br /> u <br /> ,hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lan Use <br /> Ordinance, Sanitation Code, and withall other applicable County Ordinances and the laws and regulations of the State of Wisconsin. n iQ <br /> ..... ..1.:I. ........... 1. . . .. ............ ...... ..... .. ...... ........ ................................... ....... `C — <br /> d <br /> O <br /> OWNER (please pQlntl� / ^ , CONTRACTOR or SURVEYOR or AGENT a <br /> ..--c....... W.....I.......................... .................................................................................... ....... <br /> FjL}gR ESS ADDRESS <br /> ADDRESS ADDRESS <br /> RHO................................................................................... .PHONE..................................................................... ..... <br /> .fes. . n.. ............................................... ............... ................................ ........ .. ................... <br /> PLUMBER WELL DRILLER <br /> _0 <br /> ADDRESS............................................................................ .ADDRESS................................................................. ..... O <br /> Go <br /> _. < <br /> ........................................................................................... ............................................................................................ O ri <br /> PHONE PHONE Z r. <br /> DESCRIPTION 4. Sanitary Facilities: o o ' <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> .......... ('� <br /> New Building ..... .... Type of Constructigq: , No. Bedrooms .. ...... tT� a71 <br /> —_ <br /> Addition .. .. ',(../!y Septic Tank Size Pals. .......... <br /> ...... ..... ........ / <br /> Sanitary ...7"... Size .............. ft. x .............. ft. i �d/hf .......... :� . <br /> Absorption Field Sia:Absorp ' <br /> Filling)Grading ,,,,,,,,,, Height............. Stories ............... 4a. <br /> SoilType ......................Moving .......... Area ........................... ............... <br /> Mobile Home .......... <br /> Slope ............................d.................... 7% or�* <br /> Privy .......... 3. Use (describe exactly, Tamil Perc. Rate .......................... ........ <br /> Well .......... home,garage, motel, etc. Dry Well .... <br /> ... . i <br /> Subdivision Seepage Trench .... QQ F <br /> Camping Unit .......... .................................................... Privy ..... <br /> Seepage Bed ...... f <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. In <br /> clud goad 1'.i � Q :� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway InteW <br /> r <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXIS ING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> /�/4 � c �- <br /> 1s�- o <br /> N � o <br /> Y �6 Z <br /> 0 <br /> a <br /> c—+tz �oc rV, ji �x7� 1<"( rll�.t TT I'ar®�x� Sj � 01 r�M :EW2` <br /> D m �G <br /> 'o chit <. � w m <br /> Z o o n m <br /> O 3 4 p M <br /> Fn <br /> L)iD a m <br /> ..... .... . . .... . .. .......................................... ...................................... � o fC <br /> Signat re f O r or Agent Date — <br /> x 70 <br /> Remarks :....... m IT <br /> m : <br /> n <br /> ............................................................................................................. ...... ....... <br /> 7 /Zl « <br /> T <br /> Inspection Date ..6.::,,x..G:..::.L� ....... ....... ...... .....�...................... ..... +: $ m <br /> Zoning A inistrator $ $ $ $ rn <br /> NOTE: A preliminary site inspection must he made and site approval granted on all structures inlvolving sanitary fac !tins <br /> tefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> :his application before a permit will be issued. Do not Purchase or Install a septic tank, do any plu hing or start any build <br /> ng until a permit has been issued. A permit may be revoked If misrepresentation of any of the information conveyed here- <br /> vith Is found to exist. Changes in plans or specifications shall not be made without approval of ft e Zoning Aclm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE 6,ND APPROVED. <br />